Perfectionism in anorexia nervosa:

a literature review

Bachelorthesis Psychology and Health

Author: A. Boeren (544187)

Tutor: drs. N.L.M. Damen
July 2013

Department Medical and Clinical Psychology

Tilburg University

Abstract

Anorexia nervosa (AN) is an eating disorder with an increases mortality risk and negative
psychological and physical health outcomes. Perfectionism has been proposed as a factor that
is prominent in AN patients and adversely affects outcomes, such as symptom severity,
response to treatment, and illness duration. This review focused on 19 articles to examine the
dimensions of perfectionism that play a role in AN, the persistence of perfectionism after
recovery from AN, and the influence of perfectionism on response to treatment and the
prognosis in AN. The relevant articles that were found through a literature search and the
reference lists of other articles were all published between 1994 and 2012. All studies found
that maladaptive forms of perfectionism, such as socially prescribed and self-oriented
perfectionism, were elevated in active AN cases. Maladaptive and adaptive perfectionism
seem to interact in a way that influences the body image perception of AN patients.
Perfectionism often remained elevated after treatment, and may be a prognostic factor for
unfavorable outcomes, such as a lower recovery rate and a worse prognosis. Two studies
however found that the level of perfectionism was in the normal range in long-term recovered
individuals, and the influence of perfectionism on the long-term prognosis in AN remains
unclear. Inconsistencies in the findings can be attributed to methodological aspects, such as
differences in sample sizes and differences in the diagnostic criteria that were used to
determine the presence of an eating disorder. These factors limited the comparability and the
generalizability of the results in this review. Future research is needed to clarify if
perfectionism persists after recovery from AN and how perfectionism affects the prognosis in
AN, but this review implies that clinicians should focus on treating perfectionism in AN
patients.

Keywords: Anorexia Nervosa, Perfectionism, Response to Treatment, Prognosis, Review

Table of contents
Abstract

P. 1

Table of contents

P. 2

Introduction

P. 3-5

Method

P. 6

Results
Dimensions of specific interest

P. 7-16

Persistence of perfectionism

P. 16-17

Influence of perfectionism on response to treatment and prognosis

P. 17-19

Discussion

P. 20-28

References

P. 29-32

Tables
1a. Perfectionism and its dimensions in Anorexia Nervosa (AN)

P. 33-37

1b. Persistence of perfectionism and influence on response to treatment

and prognosis

P. 38-39

Figure
Flowchart of the literature selection

P. 40

Introduction
Research on disordered eating dates back centuries ago. Anorexia Nervosa (AN) is an eating
disorder that has been of particular interest to researchers in the fields of psychology and
psychiatry, because AN is associated with an increased mortality risk. A meta-analysis by
Arcelus, Mitchell, Wales and Nielsen (2011) showed that the mortality rate for AN is 5,1 per
1000 person-years, with 1,3 out of 5,1 deaths resulting from suicide. This shows that suicide
is an important cause of death in AN patients, a finding that is corroborated by Pompili,
Mancinelle, Girardi, Ruberto, and Tatarelli (2004). The mortality rate for AN patients is
higher than the mortality rate in other psychiatric disorders (Arcelus et al., 2011), especially
when AN patients have a Body Mass Index (BMI) of 13,5 points and lower (Rosling, Sparn,
Norring & Von Knorring, 2011). Although AN is not the most common eating disorder, the
lifetime prevalence rate of AN is still estimated at 0,9% in women (Hudson, Hiripi, Pope &
Kessler, 2007).
According to the DSM-IV-TR criteria, AN is characterized by a refusal to maintain a
minimally normal body weight, an intense fear of gaining weight or becoming fat, and a
disturbance in the experience of body shape or weight (APA, 2000). AN can be further
subdivided into the restricting subtype, the purging subtype, and the binge-eating and purging
subtype (Halmi et al., 2000). AN is associated with many serious physical health problems,
such as amenorrhea (Stice, South & Shaw, 2012), damage to multiple organs, hypoglycemia,
seizures, irregular heartbeat, and even cardiac arrest (www.anred.com, 2011). Research by
Nunn, Frampton, Gordon, and Lask (2008) has shown that AN is associated with brain
abnormalities, including impairment of neural circuits in several brain structures, such as the
insula, hippocampus and amygdala.
Numerous studies have focused on the influence of personality and psychological
factors on the onset and the outcomes in AN (e.g. illness severity, duration, and recovery).
One of these factors is perfectionism. Perfectionism can be considered as a cognitive
attitudinal construct, and research on perfectionism suggests that setting excessively high
personal standards of performance for oneself is central to the concept of perfectionism
(Frost, Marten, Lahart & Rosenblate, 1990). Other characteristics of perfectionism include
concerns about making mistakes, self-doubt, and automatic negative thoughts (Frost et al.,
1990). The dominant view in the literature on perfectionism is that it is a dimensional
construct, meaning that individuals can vary in the degree of perfectionism. However,
according to the opposing categorical perspective on perfectionism two types of perfectionism
3

can be distinguished, namely adaptive perfectionism and maladaptive perfectionism (BromanFilks, Hill & Green, 2008). Adaptive perfectionism can be considered as the positive
dimension of perfectionism. It is characterized by the setting of realistic personal goals and
expectations for oneself, which leads to an enhanced self-esteem and satisfaction (TerryShort, Owens, Slade & Dewey, 1994). Maladaptive perfectionism can be considered as the
negative dimension of perfectionism. It is characterized by the setting of unreasonably high
standards for oneself, and is driven by an intense fear of failure (Terry-short et al., 1994).
Perfectionism can moreover be further subdivided into three interpersonal and intrapersonal
components, as was demonstrated by Hewitt and Flett (1995). Socially prescribed
perfectionism, as an interpersonal component, is the belief that others have very high
expectations of oneself, and is combined with a strong desire to adhere to the high standards
supposedly set by others. Self-oriented perfectionism, as an intrapersonal component, is
perfectionism that comes from having irrationally high expectations and standards for oneself
(Cockell et al., 2002). Another interpersonal component is other-oriented perfectionism,
which can be defined as the setting of unrealistically high standards of performance for others
(Hewitt & Flett, 1995). These dimensions can be seen as maladaptive forms of perfectionism
when they lead perfectionists to be overly critical of their own behaviors, allowing little or no
room for making mistakes (Frost et al., 1990). While the evidence for the categorical view on
perfectionism is limited, many researchers have now adopted this view and look at
perfectionism as a construct with distinct categories (Broman-Filks et al., 2008).
Several studies indicate that AN is associated with significantly increased levels of
perfectionism. Halmi et al. (2000) for example showed that patients with AN have higher
scores on several measures of perfectionism when compared to healthy controls. As described
earlier, perfectionism can be seen as a multidimensional construct, and in the context of AN,
studies have shown that maladaptive (Soenens, Nevelsteen & Vandereycken, 2007) or
neurotic (Davis, 1996) perfectionism, and maladaptive forms of socially prescribed and selforiented perfectionism (Cockell et al., 2002) are dimensions that are particularly important in
this population. AN patients have also been shown to be perfectionistic on a very specific
aspect of perfectionism, namely concerns over mistakes (Bulik et al., 2003), and these scores
remained elevated compared to the scores in a healthy control group, even after weight
restoration (Bastiani, Rao, Weltzin & Kaye, 1995). Moreover, Soenens et al. (2007) have
demonstrated that maladaptive forms of perfectionism are important in predicting symptom
severity in AN. More importantly, longitudinal studies on perfectionism in AN have indicated
that high perfectionism scores were a factor that was related to a lack of recovery after 2 years
4

of follow-up time (Rigaud, Pennacchio, Reveillard & Vergs, 2011), and that high
perfectionism predicted a poor prognosis after 5 years of follow-up time (Bizeul, Sadowsky &
Rigaud, 2001).
In general, researchers have reached consensus that perfectionism is an important
construct in AN patients. There is also agreement among researchers on the fact that
especially maladaptive forms of perfectionism are important in the population at hand.
However, when it comes to the persistence of perfectionism after recovery from AN, research
findings have been slightly more inconsistent. Bardone-Cone, Sturm, Lawson, Robinson, and
Smith (2010), and Nilsson, Sundbom, and Hgglf (2008) have demonstrated that the level of
perfectionism in recovered individuals is in the normal range, while other longitudinal studies
in this review indicate that perfectionism is a trait that remains elevated even after recovery.
There have also been too few studies on the influence of perfectionism on the long-term
prognosis in AN.
Despite the aforementioned inconsistencies found in some of the literature, the
importance of perfectionism in AN, and the amount of research on this topic, a literature
review on the relevant dimensions of perfectionism in AN, the persistence of perfectionism
after recovery from AN, and the influence of perfectionism on the response to treatment and
the prognosis in AN has not yet been written. Therefore, this literature review will examine
the relationship between perfectionism and AN, hereby focusing firstly on the different
dimensions of perfectionism that are prominent in AN patients, as well as the persistence of
perfectionism after recovery, and the influence of perfectionism on the response to treatment
and the prognosis in AN.

Method
As was mentioned, the aim of this review is to examine the relationship between
perfectionism and AN, hereby focusing on research that studied the different dimensions of
perfectionism in AN, the persistence of perfectionism, or the influence of perfectionism on the
response to treatment and the prognosis in AN. Therefore, a literature search was done, using
the databases of PsycINFO and PubMed.
To be included in this literature review, articles had to discuss the dimensions of
perfectionism that are relevant in AN, how perfectionism persists after recovery from AN, or
how perfectionism influences the response to treatment and the prognosis in AN.
Furthermore, the articles had to be written in English or Dutch and had to be peer-reviewed.
Publication date was not a criterion for selection, since research on AN started many years
ago, and older articles can still provide valuable insights into the relationship between
perfectionism and AN. Also, studies had to focus on adult populations, with research samples
consisting of subjects aged 18 or higher. Longitudinal studies had to include samples at the
last follow-up that consisted of subjects that were 18 years or older. Books, dissertations, and
reviews were excluded from this review.
Keywords that have been used are "perfectionism AND anorexia NOT bulimia NOT
children". This search resulted in 77 articles in PsycINFO and 54 articles in the PubMed
database. After this, articles were screened on basis of the title and abstracts to ensure that
only articles focusing on the topic at hand were included. Lastly, 52 full-text articles were
assessed for relevance for this review. By defining the search term in a very general manner,
the search yielded studies on the different dimensions of perfectionism in AN, as well as
studies that researched the persistence of perfectionism after recovery from AN, or the
influence of perfectionism on the response to treatment and the prognosis in AN.
Finally, on basis of the literature search, 13 articles were included in this review. Six
additional records were found through the reference lists of other relevant articles, so that 19
articles in total were included in this review. Figure 1 provides a flowchart of the literature
search.

Results
As described earlier, the aim of this literature review is to examine the relationship between
perfectionism and AN, hereby focusing on the relevant dimensions of perfectionism in AN, as
well as on the persistence of perfectionism after recovery from AN, and the influence of
perfectionism on the response to treatment and the prognosis in AN. The following section
will review the 19 relevant articles in further detail. In the first part articles focusing on the
different dimensions of perfectionism in AN will be discussed, whereas in the second part
articles on the persistence of perfectionism and the influence of perfectionism on the response
to treatment and the prognosis in AN will be reviewed. Due to the limited number of studies
on the influence of perfectionism on the response to treatment and the prognosis in AN, the
emphasis of this review is on the dimensions of perfectionism that are important in AN.

Perfectionism in AN: dimensions of specific interest

As was mentioned in the introduction of this review, perfectionism is a multidimensional
construct, and maladaptive dimensions in particular seem to be important in AN. All relevant
articles confirmed that perfectionism is an important factor in AN patients. Regardless of this
general consensus, researchers chose different perspectives from which they studied this
relationship. Some studies chose to study the perfectionism construct as a whole in AN
patients, and did not subdivide the construct into separate dimensions. Here, the focus will be
firstly on those studies, as they provide insight in the general importance of perfectionism in
AN. A study by the Price Foundation Collaborative group (2001) attempted to derive
behavioral phenotypes in a large sample of eating disordered patients that primarily
comprised anorexic individuals: 312 out of the 348 patients were AN patients. In order to do
so, a structured interview and several personality questionnaires were used. The Structured
Interview of Anorexic and Bulimic syndromes (SIAB) was used to collect eating disorder
diagnostic information and information about other psychopathological factors that are related
to eating disorders. The Multidimensional Perfectionism Scale (MPS) was used to assess
overall perfectionism, and in this study subjects were instructed to answer the questions of the
MPS according to how they felt when their eating disorder symptoms were at their worst. The
MPS consists of six subscales (concerns about mistakes, personal standards, parental
expectations, parental criticism, doubts about actions, and organization) that measure different
aspects of perfectionism, and together provide an overall perfectionism score. The results of
this study indicated that perfectionism is one of the five big factors that underlie the cluster of
7

personality and behavioral traits of AN patients in this sample. Therefore, it was concluded
that perfectionism, amongst others, is a trait that is often seen in eating disordered individuals,
including AN patients.
The relationship between AN and perfectionism as a personality characteristic was
also studied by Bachner-Melman, Zohar, Kremer, and Ebstein (2007), but this study focused
on studying differences between the different subtypes of AN, namely the bingeing-purging
and the restricting subtype. It also focused on studying differences between women of
different illness statuses. Three illness-statuses were defined in this study, namely currently
diagnosed with AN, partially recovered, and fully recovered. The sample consisted of 195
women with a past or present diagnosis of AN according to the DSM-IV criteria, of which 17
were currently diagnosed with AN, 107 were partially recovered, and 71 were recovered. The
control group consisted of 242 healthy controls. This study utilized self-report instruments,
such as the Eating Attitudes Test (EAT) to assess symptoms of disordered eating, the Eating
Disorder Inventory (EDI) to assess body dissatisfaction and drive for thinness, and the Child
and Adolescent Perfectionism Scale (CAPS) to assess general levels of perfectionism. Few
effects of AN subtype on personality were found, but the results demonstrated that there are
differences between women of different illness statuses. Namely, the group of AN patients
had the highest scores on measures of perfectionism, followed by partially recovered, fully
recovered, and healthy control individuals, although only the difference between the healthy
control group versus the other three groups was statistically significant. This indicates that
perfectionism is a personality variable that underlies AN in fully recovered, partially
recovered, and currently ill patients, hereby providing evidence for the notion that
perfectionism is a relatively stable personality trait.
A study that closely resembles the study of Bachner-Melman et al. (2007) is a study
done by Halmi et al. (2000), as they also focused on how perfectionism varies across clinical
subtypes of AN. The sample in this study consisted of 322 women with a DSM-IV diagnosis
of AN, of which 146 were patients with the restricting subtype of AN, 116 were patients with
the purging subtype, and 59 were patients with the binge-eating and purging subtype. Two
instruments were used to measure perfectionism, namely the MPS and the EDI, which has a
perfectionism subscale. The scores per subtype group and per subscale were compared, and
the results of this indicated that healthy controls scored lower on all perfectionism subscales,
except for the subscale 'organization'. Patients with the purging subtype of AN had higher
scores than patients with the restricting subtype on the subscale 'parental criticism', which is a
subscale that is part of the socially prescribed perfectionism dimension. As was mentioned in
8

the introduction, socially prescribed perfectionism entails the belief that others have very high
expectations of oneself, combined with a strong desire to adhere to the high standards
supposedly set by others (Hewitt & Flett, 1995). Differences in scores for each AN subtype on
the perfectionism subscale of the Eating Disorder Inventory (EDI) were not significant, but
the perfectionism scores of all three AN subtypes were significantly higher than the scores
found in a healthy control group. This study also reported that women who were more
perfectionistic when their eating disorder was at its worst had a lower lifetime lowest weight,
engaged in more ritualistic behaviors, and had a lower motivation to change (Halmi et al.,
2000).
While the previous two studies compared the diagnostic subtypes of AN, Peck and
Lightsey (2008) chose to compare women that were ill with eating disorders of differing
severity, and focused on differences in perfectionism. This led them to subdivide their sample
of 261 women into three categories; eating disordered women, symptomatic women, and
asymptomatic women, that were then compared on a number of variables. A diagnostic
interview and current bodyweight were used to determine in which category patients
belonged. The category of asymptomatic women consisted of subjects that showed no eating
disorder symptoms, while the category of symptomatic women consisted of women that
showed eating disorder symptoms that were still on a subclinical level. The eating disordered
group consisted of women showing clinical eating disorder symptoms. For the comparison of
these groups mostly self-report instruments were used, namely the Questionnaire for Eating
Disorder Diagnosis (QEDD) to differentiate between eating disordered and non-eating
disordered individuals, the EDI to measure characteristics of eating disordered patients, and
the MPS to assess overall perfectionism. The results indicated that eating disordered women
differed from symptomatic and asymptomatic women on all variables, including
perfectionism. Also, higher placement on the eating disorder severity continuum, meaning the
presence of more severe eating disorder symptoms, was associated with higher levels of
perfectionism. The eating disordered group also showed to be extremely dissatisfied with their
body, as was measured by the body dissatisfaction subscale of the EDI.
Most of the relevant literature on the relationship between perfectionism and AN
studied samples consisting of relatively young women. Forman and Davis (2005) provided
interesting new information by also including middle-aged women with eating disorders in
their study. This study compared 150 young-adult women (with a mean age of 20.7 years) to
43 middle-aged women (with a mean age of 44.6 years) that were suffering from various
eating disorders, including AN. Comparisons were made on several characteristics of eating
9

disorders, including perfectionism. The comparisons on perfectionism were made based on

scores on the EDI. Forman and Davis (2005) found that the group of middle-aged women did
not differ significantly from the young-adult group on most psychological variables, including
perfectionism. This finding indicated that perfectionism is a feature that is equally important
in young-adult and middle-aged women with eating disorders, including AN.
While most of the studies in this review either used a cross-sectional or a prospective
design, a different approach was taken by Pliner and Haddock (1995), who used an
experimental design to examine the role of perfectionism in weight-concerned and weightunconcerned women. These two groups were composed based on the participants' scores on
the Eating Attitudes test: a score of 20 or higher indicated a large amount of weight-concerns
and other eating disorder symptoms that required clinical attention, while a score of 6 or
lower indicated little to no eating disorder symptoms. It remains unknown if there were any
participants with clinical AN in the sample, but this study was included in the review since it
provides interesting insights in how perfectionism manifests itself practically in an
experimental setting. The experimental task was to name as many uses for common objects
(e.g. 'brick') as possible in a set, standard time. The 100 participants were divided into three
groups: one group received a high goal setting manipulation, in which participants were
instructed to try their best and think of at least 12 uses for the common object in each trial.
Another group received a self-defined goal setting manipulation, in which participants were
instructed to set a goal amount of uses to think of for themselves, and to try their best to reach
that goal on each trial. The third group received a low goal setting manipulation, in which
participants were instructed to try their best, and to think of at least 5 uses for the object in
each trial. The participants also received feedback on their performance on the task. Pliner
and Haddock (1995) found that extremely weight-concerned women kept striving for
unrealistically high goals in the high goal setting condition, which demonstrates the
importance of socially prescribed perfectionism in these women. Weight-concerned women
strived to live up to the standard that the experimenter asked for during the manipulation,
even when this standard seemed unreachable and unrealistic. When weight-concerned women
received negative feedback on their performance on the task, they were more adversely
affected than women that were weight-unconcerned.
From these first articles can be concluded that perfectionism in general seems
important across the different subtypes of AN and across AN of differing severity. It has also
been shown that perfectionism influences eating disordered women of younger and older

10

ages. These findings demonstrate the aforementioned general consensus among researchers
about the fact that perfectionism is an important and dominant feature in anorexic women.

Maladaptive versus adaptive perfectionism

As was described in the introduction, perfectionism can be seen as a multidimensional
construct. Some of the relevant articles took this into account, and chose to subdivide the
construct and compare and contrast specific dimensions of perfectionism. This allows
researchers to study the relationship between perfectionism and AN in more depth. As was
mentioned in the introduction, perfectionism can be divided into an adaptive and a
maladaptive dimension: adaptive perfectionism is defined as setting high standards for
oneself, and is mostly seen as positive. Maladaptive perfectionism is defined as setting high
standards for oneself and experiencing discrepancies between these standards and ones
performance, and is considered as a negative dimension.
The importance of maladaptive perfectionism was demonstrated in a study done by
Patterson, Wang & Slaney (2012). The study used self-report questionnaires to assess
adaptive and maladaptive perfectionism, such as the Almost Perfect Scale-Revised (APS-R)
to measure the adaptive and maladaptive dimensions of perfectionism, and the Perfectionistic
Self-Presentation Scale (PSPS) to assess the extent in which an individual engages in
perfectionistic self-representation. Perfectionistic self-presentation can be defined as a striving
to present oneself as perfect to the world, and can include perfectionistic self-promotion, nondisclosure of flaws, and non-display of imperfections (Patterson et al., 2012). The sample
consisted of 212 women, and was subdivided into a subgroup of asymptomatic women, a
subgroup of women with subclinical eating disorder symptoms, and a group of clinically
eating disordered women, of which six were women with clinical AN. The results of this
study showed that maladaptive perfectionism is strongly associated with eating disorder
severity: women who were ill with an eating disorder experienced a high discrepancy between
self-ascribed high standards and their perceived appearance or performance. The differences
between the three subgroups on measures of adaptive perfectionism were not significant.
Findings in this study also indicated that the women with eating disorders engaged in
perfectionistic self-presentation, and it therefore appears to be a feature of the more severe
eating disorders.
Soenens, Nevelsteen, and Vandereycken (2007) also distinguished between
maladaptive and adaptive perfectionism. They compared a group of 122 eating disordered
women, of which 67 suffered from AN, with a group of 48 healthy controls on measures of
11

maladaptive and adaptive perfectionism. These dimensions of perfectionism were measured

by translated and adapted versions of the MPS and the EDI. The results in this study indicated
that the eating disordered group and the control group differed significantly on measures of
adaptive and maladaptive perfectionism, whereby the eating disordered group scored
significantly higher on both of these dimensions of perfectionism. However, the differences
on maladaptive perfectionism were bigger than the differences on measures of adaptive
perfectionism. When the four different subtypes of eating disorders in the eating disordered
group, namely bulimia nervosa, AN restricting type, AN mixed type, and Eating Disorder Not
Otherwise Specified (ED-NOS), were compared and contrasted on measures of adaptive or
maladaptive perfectionism, no significant differences between these diagnostic groups were
found. This study indicates, as was also shown in the aforementioned study by Halmi et al.
(2000), that AN patients are more perfectionistic than healthy controls, and this difference is
most strongly demonstrated on measures of maladaptive perfectionism. Moreover, only
maladaptive perfectionism predicted symptom severity in the eating disordered group. This
highlights the importance of distinguishing between maladaptive and adaptive forms of
perfectionism when studying the AN population.
Perfectionism, as a multidimensional construct, could also be considered as a construct
consisting of several dimensions that are connected and interact with each other. This is
demonstrated in a study by Davis (1996), who proposed an interactive model in which
adaptive perfectionism was positively related to body esteem, but only when the level of
maladaptive perfectionism was low. When maladaptive perfectionism reached high levels, as
it does in most eating disordered women, this relationship reversed. These relationships were
confirmed in a sample of 123 women with an eating disorder, of which 42 were AN patients.
In this sample the Body Esteem Scale (BES) was used to determine the amount of body
esteem, the MPS was used to measure overall perfectionism, and the Neurotic Perfectionism
Scale (NPQ) was used to measure maladaptive perfectionism. This study showed that the
perception of body image in eating disordered women is an interactive function of adaptive
and maladaptive perfectionism.
As was described in the previous paragraphs, several studies in this review used the
Multidimensional Perfectionism Scale (MPS) to assess perfectionism, and Bulik et al. (2003)
chose to focus on three of its subscales in particular, namely 'concerns over mistakes', 'doubts
about actions', and 'personal standards'. The subscale 'personal standards' has been shown to
measure adaptive perfectionism, while 'concerns over mistakes' and 'doubts about actions'
measure maladaptive perfectionism (Frost et al., 1990). The sample consisted of 1010 women
12

with psychiatric disorders, of which 34 were AN patients. A structured clinical interview was
used to determine the presence of eating disorders, psychiatric disorders including anxiety
disorders, or substance use disorders in this sample. Although amenorrhea is a criterion for
the diagnosis of AN in the DSM-III, it was not a requirement for AN in this study. The
authors concluded that a high level of concerns over mistakes was specifically associated with
AN and other eating disorders. Doubts about actions were found to be associated with eating
disorders, as well as with anxiety disorders. Concerns over mistakes and doubts about actions
appeared to be two critical aspects of perfectionism in the process of better understanding the
relationship between perfectionism and AN, which again emphasizes the importance of
maladaptive forms of perfectionism in the AN population.
Finally, Terry-Short, Owens, Slade, and Dewey (1994) addressed the fact that in most
studies on perfectionism, the instruments used emphasize the maladaptive aspects of
perfectionism. Therefore, they strived to create an instrument that focused both on
maladaptive and adaptive aspects of perfectionism, and aimed to show how these different
aspects vary in different (non)clinical populations. To create this instrument, items from the
EDI, the Setting Conditions for Anorexia Nervosa Scale (SCANS), the Burns Perfectionism
Scale (BPS), the MPS, and the NPQ were taken and combined. The sample of 311 subjects in
total consisted of 255 healthy controls, 21 eating disordered women, 15 depressed women,
and 20 successful athletes. The results supported the notion that there are at least two distinct
types of perfectionism, namely adaptive and maladaptive perfectionism, and the
aforementioned groups differed significantly on these two types of perfectionism. In the group
of athletes for example, high positive perfectionism was associated with low negative
perfectionism scores. In the eating disordered group however, high scores on positive
perfectionism were associated with high scores on negative perfectionism. It is possible that
eating disordered individuals generally do not differ greatly from healthy controls when it
comes to adaptive perfectionism, but they do have significantly elevated levels of maladaptive
perfectionism, when compared to healthy controls.
As the previous studies showed, especially maladaptive forms of perfectionism are
dominant in AN patients. A high level of concerns over mistakes, which is an aspect of the
maladaptive dimension of perfectionism, is specifically associated with AN. It is also
suggested that adaptive and maladaptive forms of perfectionism interact with each other to
influence other psychological outcomes, such as body image perception. These results again
support the notion that perfectionism is an important feature in AN patients, and that it is

13

meaningful to further subdivide the construct of perfectionism into an adaptive and

maladaptive dimension when studying the AN population.

Socially prescribed and self-oriented perfectionism in AN

As the previous section has shown, mostly the maladaptive dimension of perfectionism is
prominent in AN. However, some researchers have chosen to further subdivide perfectionism
into intrapersonal versus interpersonal dimensions, namely socially prescribed perfectionism,
self-oriented

perfectionism

and

other-oriented

perfectionism.

Socially

prescribed

perfectionism, as mentioned earlier, is the belief that others have very high expectations of
oneself and is combined with a strong desire to adhere to the high standards supposedly set by
others. Therefore, this is an interpersonal dimension of perfectionism. Self-oriented
perfectionism is perfectionism that comes from having irrationally high expectations and
standards for oneself, which makes it an intrapersonal dimension. Other-oriented
perfectionism is interpersonal, and can be defined as the setting of unrealistically high
standards of performance for others (Hewitt & Flett, 1995). Clearly, these types of
perfectionism can all be maladaptive, as they again lead individuals to set unrealistically high
standards.
Cockell et al. (2002) for example showed that it is meaningful to divide perfectionism
into self-oriented perfectionism and socially prescribed perfectionism in the context of AN.
The sample in this study consisted of 21 female AN patients, a control group of 17 psychiatric
patients, and a control group of 21 healthy women. These three groups were compared on a
number of variables, including perfectionism and perfectionistic self-presentation. The
comparisons were based on scores that were obtained from several self-report instruments,
including the Eating Disorder Examination (EDE-Q) to determine the presence of an eating
disorder according to the DSM-IV criteria, the MPS to measure overall perfectionism, the
PSPS to assess perfectionistic self-presentation, the Interview for Perfectionistic Behavior
(IPB) to assess trait and stylistic dimensions of perfectionism, and the Beck Depression
Inventory (BDI) to measure symptoms of depression. Compared to the psychiatric and nonpsychiatric control group, AN patients in this sample had elevated levels of socially
prescribed and self-oriented perfectionism when measured with the MPS, even when other
important factors and confounders, such as depression, were adjusted for. This demonstrates
that the perfectionism in women with AN distinguishes them from individuals with mood
disorders. The results of the IPB corroborated the finding that self-oriented and socially
prescribed perfectionism are elevated in AN patients. Furthermore, the scores on trait and
14

self-presentation dimensions of perfectionism were higher in the group of women with AN

than in the psychiatric and the non-psychiatric control group. This study also demonstrated
that AN patients want to present themselves to the outside world as perfect, and that they
therefore strive for non-disclosure of their imperfections. As was mentioned earlier, this is a
tendency that is referred to as perfectionistic self-presentation. This finding on perfectionistic
self-presentation in AN was also demonstrated by Patterson et al. (2012).
Interestingly, the study by Cockell et al. (2002) found mean scores for socially
prescribed perfectionism on the MPS that were substantially higher than the scores that
Bastiani et al. (1995) found in their sample of 19 anorexic women and 10 healthy controls. In
the group of anorexic women, 11 women were underweight and 8 were weight-restored.
Bastiani et al. (1995) administered the Frost MPS and the Hewitt MPS to assess overall
perfectionism, and the EDI to assess perfectionism and eating disorder symptoms in this
sample. Apart from the higher scores on socially prescribed perfectionism, the findings in the
study by Bastiani et al. (1995) largely parallel the findings in the study by Cockell et al.
(2002): underweight AN patients had higher levels of socially prescribed and self-oriented
perfectionism when compared to the group of healthy controls. Weight-restored women
continued to score higher than healthy controls on self-oriented perfectionism only, as was
measured by the Hewitt MPS. A similar result was found based on the EDI scores:
underweight and weight-restored anorexic women had higher scores on the subscale
'perfectionism' than healthy controls. An interesting finding was that underweight and weightrestored anorexics both did not score higher than the control group on the subscale 'parental
expectations' of the Frost MPS. This subscale assesses if parents had excessively high
standards for the patient, and this finding suggests that AN patients in this sample experienced
their perfectionism mostly as self-imposed. Lastly, no differences between the AN group and
the control group on other-oriented perfectionism were found.
One study focused on self-oriented perfectionism in particular. Watson, Raykos,
Street, Fursland, and Nathan (2011) sought to find mediators between self-oriented
perfectionism and eating disorder pathology. Their sample consisted of 201 women, of which
34 were AN patients. After an intake assessment and a diagnostic interview to determine the
presence of an eating disorder, the EDI and EDE-Q were administered to measure
perfectionism and eating disorder pathology. The results that were found demonstrate that the
relationship between self-oriented perfectionism and eating disorder psychopathology is
mediated by shape and weight overevaluation and conditional goal setting, which is defined
as the conviction that achieving a certain goal is crucial to achieving a higher-order end-state,
15

such as happiness. In this sample, women with a conditional goal setting cognitive style
suffered from more severe eating disorder pathology, and this study as a whole contributes to
the increasing amount of evidence that perfectionism as a personality trait is strongly related
to eating disorders.
The previous studies confirmed that mainly socially prescribed perfectionism is an
important dimension in AN, as AN patients will try to achieve unrealistically high standards
set for them by others and by themselves. Other-oriented perfectionism appeared to be of little
importance in AN. Another interesting finding was the fact that anorexics engage in
perfectionistic self-presentation. While self-oriented perfectionism is also often elevated and
therefore important in AN, the relationship between this dimension of perfectionism and
eating disorder pathology seems to be mediated by other variables.

Persistence of perfectionism
When considering the importance of perfectionism in AN, which has been demonstrated in all
of the previous studies, the question arises whether or not perfectionism is a stable and
therefore persistent characteristic in AN patients, even after their recovery. Several articles
studies the possible persistence of perfectionism after AN.
For example, Bastiani et al. (1995) found that perfectionism is a trait that remained
elevated in their sample of 19 AN patients when compared to a group of healthy controls,
even after weight restoration. As was mentioned earlier, perfectionism and eating disorder
pathology were assessed with the EDI, the Frost MPS, and Hewitt MPS. In this sample, 11
women were assessed when they were underweight and the other 8 women were assessed four
weeks after their body weight was restored to a healthy level. The results showed that even
after weight restoration, overall perfectionism remained prevalent in anorexic women.
Soenens et al. (2007) supported this finding by showing that in a sample of 170 women, of
which 67 suffered from AN, adaptive and maladaptive perfectionism scores on the MPS and
EDI were lower after their sample of anorexic women followed a treatment specifically
designed to treat eating disorders. Compared to a control group however, the scores on
adaptive and maladaptive perfectionism in the AN group were still significantly elevated after
this treatment, again illustrating the persistent and rigid character of perfectionism in AN.
While the previous suggests that the levels of perfectionism remain elevated in AN
patients even after treatment and weight restoration, rather different results were found in a
study done by Bardone-Cone, Sturm, Lawson, Robinson, and Smith (2010). This study used a
sample consisting of 157 women, of which 55 were active eating disorder cases, 17 were AN
16

cases, 15 were partially recovered cases, 20 were fully recovered cases, and the 67 others
formed a group of healthy controls. Structured interviews, the EDE, the MPS, the PSPS, and
the Perfectionism Cognitions Inventory (PCI) were used to determine the level of
perfectionism and perfectionistic cognitions across different stages of recovery. The results
indicated that the level of perfectionism in fully recovered individuals is comparable to the
level of perfectionism found in healthy controls. This level of perfectionism also significantly
differed from the level of perfectionism found in individuals that are partially recovered or
still eating disordered. This pattern occurred across all forms of perfectionism that were
measured in this sample, including perfectionistic self-presentation and trait perfectionism,
and this finding shows that the persistence of perfectionism after recovery from AN is not as
certain as the other studies suggested. This result is furthermore supported by Nilsson,
Sundbom, and Hgglf (2008), who found similar results for long-term recovered individuals
in their longitudinal study of 91 AN patients. At the last follow-up, 68 AN patients
participated. The EDI was used to measure perfectionism in this sample, and the results
showed that long-term recovered individuals had an EDI 'perfectionism' score that was within
the normal range. This again demonstrates that persistent perfectionism after recovery from
AN may not be that evident.

Influence of perfectionism on response to treatment and prognosis

Since perfectionism is such a common trait in AN patients, one would expect that it may also
have an influence on the response to treatment and the prognosis in this disorder. A few
researchers have actually focused on studying the influence of perfectionism on the response
to treatment for AN. An example of this is the study done by Sutandar-Pinnock, Woodside,
Carter, Olmsted, and Kaplan (2002). This study administered the MPS and the EDI to assess
overall perfectionism and eating disorder pathology in a sample of 73 AN patients, of which
71 were women. All participants received at least 4 weeks of treatment in an inpatient
treatment program specifically designed to treat AN. In this study, amenorrhea was not a
requirement for a diagnosis with AN. In this study, a positive outcome was defined as 'no
symptoms and a normal weight', while a negative outcome was defined as 'any other situation'
than having a normal weight and no symptoms. Patients with a low score on the subscale
'perfectionism' of the EDI had a better response to treatment, which in turn was associated
with more positive outcomes. Higher degrees of perfectionism at pre-treatment were
associated with poorer response to treatment, which suggests that patients with high
perfectionistic tendencies have more difficulty adhering to a treatment program. Interestingly,
17

the EDI 'perfectionism' scores in recovered AN patients in this sample were similar to those of
a control group, while perfectionism scores on the MPS remained elevated in recovered AN
patients when compared to the scores of a healthy control group.
The aforementioned longitudinal study done by Nilsson et al. (2008) supports the
findings by Sutandar-Pinnock et al. (2003), by showing that individuals with a lower
perfectionism score at admission to a psychiatric clinic had a better response to treatment and
better outcomes at follow-up. This study utilized the EDI, the Global Assessment Functioning
(GAF), and the Symptom Checklist-90 (SCL-90) to study perfectionism and a range of
psychological and psychiatric symptoms. Examples of better outcomes according to this study
include a decrease in eating disorder symptoms, a decrease in obsessive-compulsive
symptoms as measured by the SCL-90, and an improvement of the Global Assessment
Functioning scores as measured by the GAF. In this sample, levels of perfectionism remained
the same while symptoms of disordered eating decreased over time. The results of this study
indicated that low levels of perfectionism in eating disordered individuals could be of
prognostic value: patients with high levels of perfectionism may suffer from a longer illness
duration than patients with low levels of perfectionism. In sum, the previous studies suggest
that high levels of perfectionism in AN patients lead to a poorer response to treatment, and
this therefore means that AN patients have more difficulty completing a treatment program.
This in turn can lead to poorer outcomes.
A question that remains is if there is an influence of perfectionism on the prognosis in
AN. Bizeul, Sadowsky, and Rigaud (2001) studied this influence in a longitudinal study of 26
eating disordered patients. The Eating Disorder Inventory (EDI) was used to study the
prognostic value of the initial EDI scores in this sample, and the results showed that the
higher the initial score on the EDI subscales 'perfectionism' and 'interpersonal distrust', the
worse the prognosis after 5 years of follow-up. Unfavorable outcomes in this study were
defined as 'relapse or remaining sick'. The group of 13 patients with unfavorable outcomes in
this sample, as opposed to the other group consisting of 13 fully recovered individuals, had
significantly higher scores on the EDI 'perfectionism' subscale. Bizeul et al. (2001) therefore
concluded that the total EDI score and the scores on 'perfectionism' and 'interpersonal distrust'
could be predictive of long-term outcomes, such as the recovery, in AN patients. High EDI
scores are then seen as predictive of a worse long-term prognosis in AN.
Lastly, another longitudinal study done by Rigaud, Pennacchio, Reveillard, and
Vergs (2011) followed a sample of 484 AN patients, of which 462 were female. The aim of
this study was to study the long-term prognosis of AN, and to do so, Rigaud et al. (2011)
18

followed the aforementioned sample for a mean duration of 13 years. The instruments that
were used to measure perfectionism in this sample were the EDE and the EDI. This study
found that high initial levels of perfectionism were, amongst other factors, linked to lower
recovery rates from AN after two years. However, bad outcomes after 13 years of follow-up,
whereby bad outcomes were defined as a low BMI, abnormal eating behaviors, or the
presence of multiple binge-eating or purging episodes a week or excessive exercise, were not
predicted by perfectionism. Perfectionism was therefore not predictive of the long-term
prognosis in this sample.
Findings in these studies show that there is not yet a general consensus among
researchers about whether perfectionism truly remains elevated in formerly eating disordered
individuals. While two studies showed that perfectionism is a trait that remains elevated in
former AN patients, two other studies argued this finding by demonstrating that the levels of
perfectionism in fully recovered individuals are in the normal range. High scores on measures
of perfectionism do seem to be related to a poorer response to treatment and a longer illness
duration, but the influence of perfectionism on the prognosis in AN needs further clarification.
In sum, this section showed that perfectionism is a characteristic of many AN patients,
and elevated levels of perfectionism for the most part seemed to persist after weightrestoration and recovery. It has been demonstrated that especially maladaptive forms of
perfectionism are elevated in AN, including socially prescribed perfectionism and
perfectionistic self-presentation. High scores on measures of perfectionism in AN patients
seem to lead to a poorer response to treatment, lower recovery rates and a worse prognosis
after 5 years. While all studies indicated that perfectionism plays a role in AN patients,
findings have been more inconsistent when it comes to the persistence of perfectionism, and
research on the influence of perfectionism on the long-term prognosis in AN is lacking.

19

Discussion
In this literature review the relationship between perfectionism and anorexia nervosa (AN)
was examined, hereby focusing mainly on different dimensions of perfectionism that are
prominent in AN, but also on the persistence of perfectionism after AN, and the influence of
perfectionism on the prognosis and the response to treatment for AN. After an extensive
literature search, 19 relevant articles were found and summarized.
Based on the articles discussed in the previous section, a general conclusion is that
perfectionism is an important feature in AN patients, as was confirmed by all the included
articles. Firstly, AN patients have elevated scores on several measures of perfectionism. Most
studies in this review used the Multidimensional Perfectionism Scale (MPS) and the Eating
Disorder Inventory (EDI), and there was a general consensus that overall perfectionism scores
on the MPS and EDI are elevated in the AN population. Several studies chose to focus on
specific dimensions of perfectionism, such as adaptive versus maladaptive perfectionism.
Maladaptive perfectionism is a negative dimension of perfectionism that is elevated in AN
patients. Furthermore, socially prescribed perfectionism and self-oriented perfectionism are
also elevated in the AN population when compared to healthy control groups. Lastly, AN
patients engage in perfectionistic self-presentation.
The findings have not been as equally consistent when it comes to the persistence of
perfectionism after AN and the influence of perfectionism on the prognosis in AN. Most
studies indicated that perfectionism is a construct and trait that remains elevated in AN, even
after weight restoration to a healthy level. Individuals with lower scores on measures of
perfectionism in general responded better to treatment for their eating disorder, which
suggests that AN patients that are highly perfectionistic may be at risk for longer illness
duration. In contrast, Bardone-Cone et al. (2010) reported that individuals that were recovered
from AN had levels of perfectionism that were comparable to the level of perfectionism that
was found in a healthy control group. Nilsson et al. (2008) supported this finding by showing
that long-term recovered individuals had perfectionism scores that were in the normal range
as well. This demonstrates that the persistence of perfectionism after AN is not evident. Also,
while Bizeul et al. (2001) demonstrated that high perfectionism led to a worse prognosis after
5 years, Rigaud et al. (2011) were unable to replicate this result after 13 years of follow-up. In
short, perfectionism is a feature that is prominent in AN sufferers, and maladaptive forms of
perfectionism in particular seem to adversely affect outcomes such as symptom severity and
illness duration. High perfectionism also leads to a poorer response to treatment and a lower
20

recovery rate. However, more research is needed to study the relationship between
perfectionism in AN and its influence on the prognosis in this eating disorder. More research
on the possible persistence of perfectionism after recovery from AN is also warranted, as it
may be a risk factor for relapse.
As described earlier, a fairly nonambiguous conclusion could be drawn when it comes
to the importance of perfectionism in AN and the specific dimensions of perfectionism that
are dominant in this population. Several studies found that especially maladaptive
perfectionism, self-oriented perfectionism, and socially prescribed perfectionism are of
importance in AN. This conclusion concerning the general importance of perfectionism in AN
could be drawn because most of the relevant articles the same instruments to measure
perfectionism, namely the Multidimensional Perfectionism Scale (MPS), Eating Disorder
Inventory (EDI) which has a subscale 'perfectionism', and the Perfectionistic Self Presentation
Scale (PSPS) in studies that also focused on perfectionistic self-presentation in AN. This
increased the comparability of the studies and therefore can be considered as a strength of this
review. Also, most studies were cross-sectional or longitudinal, and this comparability in
study design is a methodological aspect that made the studies more comparable.
Furthermore, a lot of the studies used control groups, which can be seen as a strength
and a weakness at the same time. On one hand, the presence of a control group makes it
possible to compare the results of an AN sample to a sample of healthy controls, and to come
to a conclusion on the differences in overall perfectionism in the AN population versus the
general healthy population. On the other hand, the control groups that were used in the studies
were mostly composed of very healthy control subjects with no issues whatsoever, and they
did not vary much in age, sex, and level of education: most control groups consisted of
relatively young women with normal and high levels of education. Bardone-Cone et al. (2010)
attempted to tackle this issue by using a control group that consisted of women that only
fulfilled one criterion, namely 'absence of an eating disorder'. This made the control group in
this study more representative of the general population.
The overall strength of this review can be found in the fact that it is the first review to
bring studies on perfectionism in AN, the persistence of perfectionism after AN, and the
influence of perfectionism on the prognosis and the response to treatment for AN together for
critical analysis. However, an issue that most studies dealt with is the possibility that the
elevated perfectionism scores that they found are representative of a so called 'scarring effect',
namely the possibility that premorbid perfectionism scores were comparable to those of
control groups, and that perfectionism could have emerged or have become exacerbated
21

simultaneously with the eating disorder symptoms (Bachner-Melman et al., 2007). This
makes it difficult to determine with certainty whether perfectionism is a trait that is already
established in anorexics, or if perfectionism is caused or worsened by AN.
There are some other (methodological) aspects that hampered the comparability of the
included studies. A first methodological aspect that could explain some of the inconsistent
findings on the persistence of perfectionism after AN and the influence of perfectionism on
the prognosis in AN, is the fact that several longitudinal studies dealt with a relatively high
drop-out rate. Nilsson et al. (2008) for example studied a sample of 68 individuals in their
final analyses after 16 years, which corresponds to a group that was 25% smaller than the
original sample. If the entire original sample was used, the end results of this study would
have been more reliable.
Also, an important criterion that differed among the longitudinal studies in particular,
is how each study defined 'recovery'. Bardone-Cone et al. (2010) also highlighted this issue
and described that while some studies mostly use physical measures (e.g. a specific BMI),
others use cognitive measures (e.g. no more maladaptive thoughts related to eating) to
determine recovery. The study by Bachner-Melman et al. (2007) for example defined
recovery as "a BMI above 17.5, regular menstruation for at least three months (unless birth
control pills were taken), no regular bingeing or purging symptoms for at least eight
consecutive weeks, and no excessive obsessions about food", while Rigaud et al. (2011)
defined recovery criteria of having a normal and stable bodyweight with a BMI above 18.5,
no excessive exercising, and normal eating behavior. Bardone-Cone et al. (2010) also made a
"score within 1 standard deviation of community norms on all subscales of the Eating
Disorder Examination-Questionnaire" a necessary criterion for eating disorder recovery.
These definitions of recovery differ in strictness, and this makes it difficult to compare and
contrast the different studies. Bardone-Cone et al. (2010) therefore suggested that in future
studies, recovery should be defined in a way that ensures physical, behavioral, and
psychological recovery.
Additionally, another problem in the longitudinal studies in this review is that there
were large differences in the amount of follow-up time. The study done by Sutandar-Pinnock
et al. (2002) for example followed-up after 6 and 24 months after treatment, while Nilsson et
al. (2008) followed up after 8 years and again after 16 years. Interestingly, the study done by
Nilsson et al. (2008) found perfectionism scores for long-term recovered individuals that
differed from the scores that were found in some of the other studies, as was described earlier.
This demonstrates that the amount of follow-up time is an important factor, as it can influence
22

the results and conclusions in a study. Only studies that do a follow-up after a considerable
amount of years can look at how perfectionism changes in a specific group of individuals as
this group moves from ill with AN to long-term recovered.
Furthermore, the fact that the studies differed in the criteria they used to determine
whether individuals in their sample suffered from a clinical eating disorder or not is another
issue in this review. While most studies determined this based on the DSM-IV criteria for
eating disorders, not every study used amenorrhea as a criterion to determine whether
someone suffered from AN. Evidently, studies that did use amenorrhea as an inclusion
criterion researched samples of women that were generally of worse physical health, because
amenorrhea is an issue that mostly arises in women that are severely underweight and/or
malnourished. This difference hampered the comparability of the studies.
The fact that the studies in this review used samples that varied significantly in size
also makes the results more difficult to compare. The sample sizes ranged from a sample size
of 26 patients, of which 20 were AN patients (Bizeul et al., 2001), to a sample size of 1010, of
which 34 were AN patients (Bulik et al., 2003). The largest sample of anorexics consisted of
484 patients (Rigaud et al., 2011). Even when the overall sample in a study was relatively
large, the amount of AN patients was usually fairly small. This makes the generalization of
the results to the entire population of AN patients more problematic, and this should therefore
be done with caution.
Moreover, not every study clearly stated which part of their sample consisted of AN
patients: some simply mentioned that their sample consisted of 'eating disorder cases'. Peck
and Lightsey (2008) merely stated that their sample consisted of 'symptomatic' and
'asymptomatic' women, as did Patterson et al. (2012), who divided their sample into a clinical,
subclinical and asymptomatic group. Lastly, Pliner and Haddock (1995) merely specified that
their sample consisted of a group of 'weight-concerned' and a group of 'weight-unconcerned'
women. Since this study was most likely done with a nonclinical sample of weight-concerned
women, generalization of these results to the population of anorexic women should be done
with caution. Replication of this study with a clinical sample of eating disordered women is
necessary. All of the above makes it more difficult to determine whether perfectionism is
specifically related to AN, or whether it is related to eating disorder symptoms in general.
While there are studies that found that perfectionism is elevated in the part of their sample
that consisted of anorexics specifically, the strength of this review and the quality of the
individual studies would increase if all studies clearly stated which part of their sample
consisted of AN patients. It also remains unknown whether studies successfully and
23

accurately assigned their subjects to the correct diagnostic eating disorder category, which is
an issue that is also mentioned by the Price Foundation Collaborative Group (2001).
Diagnostic interviews were often used to determine the correct eating disorder label for each
patient in a sample, but it can be difficult to do so since eating disorders are rarely as clearly
defined as DSM-criteria make them seem. Patients often suffer from a combination of
symptoms from several diagnostic eating disorder categories. When patients are classified
into the wrong eating disorder subcategory, the end results become less reliable.
Another issue that makes the generalization of results difficult is the fact that most
studies used samples that consisted mostly of females. Recent studies have shown that the
amount of male anorexics has increased dramatically over the last years, and men now
represent about 10 to 20 percent of the cases of AN (Jones & Morgan, 2010). While the
amount of male AN patients is increasing, the fact that the samples in this literature review
mostly consisted of women makes it difficult to generalize the findings on perfectionism in
AN to the opposite gender. This is a limitation, because studies have shown that eating
disorders differ in clinical presentation in men and women (Jones & Morgan, 2010).
Furthermore, most samples consisted of young women with mean ages that were
anywhere between 18 and 30 years. The only study that specifically focused on anorexia in
middle-aged women was the study done by Forman and Davis (1995), in which the mean age
of the sample of middle-aged women was 44.6 years. This is surprising, when considering
that AN also affects the elderly (Lapid et al., 2010), a fact that is unfortunately often
overlooked. Generalization of the findings on perfectionism in AN from young samples to
older samples could be problematic and should be done with caution before more research in
older samples has been done.
Lastly, another difference between the included studies is that only some studies chose
to use interviews. Using an interview to discuss and determine whether traits such as
perfectionism are present makes the end results more reliable than using self-report measures
alone, as was also pointed out by Cockell et al. (2002). An interview is also a helpful tool in
assessing the severity of eating disorder symptoms. Clearly, the use of interviews can be seen
as a strength of several studies in this review, but the fact that not all studies used interviews
to assess perfectionism and eating disorder pathology in their sample makes the results more
difficult to compare.
In short, the most important strengths of this review are the comparability of test
scores because of the overlap in the instruments that the studies used, the use of control
groups, and the fact that this is the first review on this subject in particular. Weaknesses of
24

and differences between the studies in this review include the differences in sample size and
the fact that most studies used samples consisting of young women, the differences in
diagnostic criteria used, and differences in how recovery was defined by different researchers.
As these aspects limit the comparability of the studies and the generalizability of the findings,
any conclusions should be drawn with caution. While it is now clear that perfectionism plays
a role in AN, more research is necessary to further clarify and verify this relationship, the
persistence of perfectionism after AN, and the influence of perfectionism on the prognosis in
AN.
After critically discussing the studies in this review, several recommendations for
future research can be made. From a methodological viewpoint, more studies with a
longitudinal design are needed. The follow-up time in future longitudinal studies should
increase, because this will help clarify the role that perfectionism has in long-term recovered
AN patients, and it will also show if and how perfectionism changes overtime in a specific
sample.
Furthermore, future research should focus research samples that better represent the
AN population. This means that future studies should include more men in their sample and
that the subjects should vary more in age, considering the fact that eating disorders in the
elderly are too often overlooked. As mentioned earlier, eating disorders do differ in clinical
presentation in men, and the relationship between perfectionism and AN in men specifically
has not been well researched yet. Further research could yield new, interesting information
that could help the population of male AN patients. Future control groups should also consist
of subjects that better represent the general population, which means that control groups
should include men and women of a variety of ages and levels of education, and with and
without psychological and psychiatric issues.
Also, future research could be of more value if studies focused on the several
dimensions of perfectionism instead of studying the construct as a whole, since it has been
shown that there are specific dimensions of perfectionism that are important in AN.
Moreover, most studies in this review focused on measuring the construct of perfectionism in
AN. Not many studies actually focused on researching how perfectionism influences the
anorexic, and which mechanisms could be of importance, while keeping in mind that it would
be difficult to determine any causal relationships. Why maladaptive perfectionism in
particular has such a pathological meaning in AN also remains unclear and should be studied
further.

25

Another focus for future research should be on how perfectionism interacts with other
relevant psychological factors to influence AN severity. Factors such as depression (Mattar,
Thibaud, Huas, Cebula & 2012) and anxiety (Lavender et al., 2013) have been shown to play
an important role in AN, and it is possible that perfectionism, anxiety, and/or depression
interact and have a unique, combined influence on outcomes in AN. This suggestion was also
made by Bardone-Cone et al. (2010), who suggested that levels of recovery could be
influenced by premorbid levels of anxiety, depression and perfectionism.
Lastly, how perfectionism influences relapse rates in AN is also unknown. Since
perfectionism seems to remain elevated after AN patients followed treatments that are
specifically designed to treat AN, it is hypothesized that perfectionism could be a possible
contributor to relapse (Soenens et al., 2007). If such a negative influence of perfectionism can
be found, this implies that clinical practitioners should put specific emphasis on treating and
changing maladaptive perfectionistic thoughts and behaviors in AN patients. However, the
opposite could also be true, namely that treatment that focuses on changing the maladaptive
eating behaviors and symptoms over time allows AN patients to let go of their perfectionistic
standards for themselves. The best temporal order for treatment should therefore be studied.
Research on how perfectionism affects outcomes following specific treatments (e.g. cognitive
therapy, group therapy) is also fairly scarce. More research on this topic could be helpful for
the development of more effective treatment programs.
In sum, although research on the relationship between perfectionism and AN is
lacking in some areas, a number of clinical implications are implied now that it is clear that
perfectionism plays a role in AN.

Clinical implications
As mentioned above, this literature review implies that perfectionism is a distinct
characteristic in AN patients, and that especially maladaptive forms of perfectionism are
prevalent in this population. Women with high levels of perfectionism are at risk of more
severe illness and longer illness duration. As perfectionism is clearly important in AN,
clinicians should take this factor into consideration. Since perfectionism seems to be linked to
illness severity, this implies that long-term and multimodal psychotherapy is needed in this
population. A better understanding of the relationship between perfectionism and the
prognosis in AN is also important, because of the health risks and the increased mortality rate
in this population. A clearer view on this relationship would be beneficial for the development
of more effective treatment and prevention programs. When treatment programs become more
26

effective, physical health related outcomes will improve as well. Since AN has an enormous
negative impact on the quality of life of anorexic individuals, especially when it is combined
with purging behaviors that are often seen in AN patients (Ackard, Cronemeyer, Franzen,
Richter & Norstrom, 2011), a better understanding of the importance of perfectionism may
help improve this quality of life.
Also, this review implies that perfectionism is a factor that influences treatment
success in a negative manner. Therefore, treatments could become more successful if
clinicians aim to treat and lower perfectionism in AN patients. Perfectionistic selfrepresentation in particular may be a risk factor for more severe eating disorder symptoms,
which implies that this should become a focus point in treatments (Patterson et al., 2012).
Perfectionistic self-presentation is also a factor that should be taken into consideration when
choosing the correct treatment for an AN patient. As perfectionistic self-presentation is about
a non-disclosure of imperfections, this implies that group therapies may not be a good choice
when treating AN patients that engage in perfectionistic-self presentation, because group
therapies require the sharing of problems and imperfections with other patients (SutandarPinnock et al., 2003). Also, considering the fact that relapse in AN is very common (Carter,
Blackmore, Sutandar-Pinnock & Woodside, 2004), and that maladaptive perfectionism could
be a risk factor for relapse (Soenens et al., 2007), AN patients should be encouraged to
undertake long-term therapy that also focuses on lowering their maladaptive perfectionistic
standards, as this may help prevent relapse.
Currently, family-based treatment and cognitive behavioral therapy are treatments that
are often and successfully used to treat AN (Dalle Grave, Calugi, Doll & Fairburn, 2013), and
in the future it could be useful to incorporate a specific module in therapies and treatments
that focuses on perfectionistic thoughts and behaviors related to eating disorders (e.g. 'if I eat
this, I will have failed myself and others again'). It has been shown that cognitive behavioral
treatment is effective in lowering perfectionism in other clinical groups, such as patients with
social phobia (Ashbaugh et al., 2007), which implies that this type of treatment may also be
effective in lowering perfectionism in other clinical population, such as the AN population.
Although the specific mechanisms of influence in the relationship between
perfectionism and AN remain unclear, perfectionism is a factor in AN patients that should
receive more attention during treatments while the amount of research on this topic extends.
This also implies how important it is for clinicians that treat AN to have accurate and up to
date empirical information, as new findings on perfectionism in AN can help improve the
effectiveness of treatment programs.
27

In conclusion, this literature review showed that especially maladaptive forms of

perfectionism are an important characteristic in AN. Patients with high scores on measures of
perfectionism may respond poorly to treatment and therefore suffer a longer illness duration,
while fully recovered individuals seemed to have levels of perfectionism that were in the
normal range in some studies. More research is needed to clarify if and how perfectionism
influences relapse in AN. It is also important to study how perfectionism interacts with other
(psychological) factors to influence AN severity and outcomes. If the comparability of studies
increases and the quality of samples improves, the relationship between perfectionism and AN
could be further clarified, which can help improve the quality and effectiveness of treatment
and prevention programs for AN.

28

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32

Table 1a. Perfectionism and its dimensions in anorexia nervosa (AN).

Authors and
Year

Sample

Design

Time of
measurement

Follow-up
time

Variables

Relevant
instruments

Main results

Bachner-Melman,
Zohar, Kremer &
Ebstein, 2007

N=437, of which 195

women with
anorexia nervosa
(AN) (17 ill, 107
partially recovered,
71 recovered) and
242 controls

Cross-sectional

Post-diagnosis with AN

No follow-up

Obsessiveness,
perfectionism, fear of
failure, endorsement of
the thin ideal, self-esteem,
harm avoidance, novelty
seeking, persistence, and
reward dependence

Controls differed
significantly from all
AN groups on almost
all variables,
subtypes differed
only on variable
novelty seeking

Bastiani, Rao,
Weltzin & Kaye,
1995

N=29, of which 19
women with AN and
10 controls

Cross-sectional

11 assessed when
underweight, 8 assessed 4
weeks after healthy
weight restoration

No follow-up

Organization, overall
perfectionism, selforiented, socially
prescribed and other
oriented perfectionism,
drive for thinness,
bulimia, body
dissatisfaction,
ineffectiveness,
interpersonal distrust,
interoceptive awareness,
maturity fears

Diagnostic interview,
eating disorder
inventory (EDI),
Brief Symptom
Inventory, Eating
Attitudes Test-26
(EAT), Obligatory
Exercise
questionnaire,
Achievement
Motivation Scale,
Child and
Adolescent
Perfectionism scale,
Rosenberg SelfEsteem Scale,
Maudsley ObsessiveCompulsive
Inventory,
Tridimensional
Personality
Questionnaire
EDI, Hewitt
Multidimensional
Perfectionism Scale
(MPS) and Frost
MPS assessments

Women with AN are

perfectionistic on all
measured aspects of
perfectionism, except
parental expectations
and other-oriented
perfectionism.
Perfectionism
persisted after weight
restoration

33

Authors and
Year

Sample

Design

Time of
measurement

Follow-up time

Variables

Relevant
instruments

Main results

Bulik et al., 2003

N=1010 women with

psychiatric disorders,
of which 34 with AN

Retrospective

Two years after

participating in large twin
study

No follow-up

Concerns over
mistakes, doubts
about actions,
personal standards

MPS (adapted
version), and
diagnostic interviews
to determine
psychiatric disorders

Cockell et al., 2002

N=59, of which 21
women with AN, 21
normal controls and
17 psychiatric
controls

Cross-sectional

Questionnaires completed
subsequent to interviews

No follow-up

Eating disorder
symptoms, several
dimensions/facets of
perfectionism,
perfectionistic
behavior, depression,
self-esteem,
psychiatric
disturbance

Davis, 1996

N=123 women with

an eating disorder
(ED), of which 42
with AN

Correlational

At admittance for ED
treatment

No follow-up

Body esteem,
perfectionism,
neurotic
perfectionism,
neuroticism

Eating Disorder
Examination (EDE),
MPS, Perfectionistic
Self-Presentation
Scale (PSPS),
Interview for
Perfectionistic
Behavior (IPB),
Beck depression
Inventory (BDI),
Hamilton Depression
Rating Scale
(HDRS), RSES, and
Global Assessment
Scale (GAS)
Body Esteem Scale
(BES), MPS,
Neurotic
Perfectionism
Questionnaire
(NPQ), and Eysenck
Personality
QuestionnaireRevised (EPQ-R)

Elevated scores on
subscale 'concerns
over mistakes'
specifically
associated with AN.
'Doubts about actions'
associated with both
eating and anxiety
disorders.
Women with AN had
elevated levels of
self-oriented and
socially prescribed
perfectionism
compared to control
groups, even when
other factors are
controlled for.

This study showed

that body-image
perception in eating
disorders should be
seen as an interactive
function of normal
and neurotic
perfectionism.
Normal perfectionism
is positively related
to body esteem but
only when neurotic
perfectionism is low.

34

Authors and
Year

Sample

Design

Time of
measurement

Follow-up time

Variables

Relevant
instruments

Main results

Forman & Davis,

2005

N=193 women with

an ED, of which 77
women with AN,
subdivided into
groups (young adults
and middle-aged
women)
N=322 women, of
which 146 women
with AN subtype
restricting, 116 AN
subtype purging and
60 with AN subtype
binge-eating and
purging

Cross-sectional

At admission and
discharge

At discharge from
treatment

EDI-2, BDI, Beck

Anxiety Inventory
(BAI), and Body
Shape Questionnaire
(BSQ)

Cross-sectional

Post-diagnosis with AN

No follow-up

Eating disorder
attitudes and
symptoms,
depression, anxiety,
body shape, media
influence on body
image
Perfectionism
(different aspects),
obsessive compulsive
behaviors,
preoccupations/rituals
related to food,
weight, eating, body,
exercise

Patterson, Wang &

Slaney, 2012

N=212 women

Cross-sectional

During partial
hospitalization (ED
subjects) and during
university classes (healthy
subjects)

No follow-up

Eating disorder
symptoms,
perfectionism, selfpresentations,
depression, social
support, relationship
depth, interpersonal
conflict, interpersonal
wellbeing

Questionnaire for
Eating Disorder
Diagnosis (Q-EDD),
Almost Perfect Scale
(APS) (revised),
PSPS, Quality of
Relationships
Inventory (QRI), and
Relational Health
Indices (RHI)

Peck & Lightsey,

2008

N=261 women, of
which 31 with an
ED, 95 with ED
symptoms and 135
asymptomatic
controls

Cross-sectional

During university hours

No follow-up

Global self-worth,
eating disorder
attitudes and
symptoms,
perfectionism, DSMIV criteria for eating
disorders

Q-EDD, EDI-2,
MPS, and RSES

Features related to
eating disorders such
as perfectionism are
equally important to
middle-aged women
as they are to
younger patients
AN subjects scored
high on
perfectionism
subscales of the
instruments used.
Scores on the MPS
were related to the
total score and the
motivation-forchange subscale
score of the YBCEDS.
Maladaptive
perfectionism was
strongly associated
with eating disorder
severity. The three
groups differed
significantly on
measures of
perfectionism. There
were no significant
differences in
relational health and
quality.
Higher perfectionism
scores were found
for women with
more severe eating
disorders when
compared with
symptomatic and
asymptomatic
women.

Halmi et al., 2000

MPS, EDI-2, and

Yale-Brown-Cornell
Eating Disorder
Scale (YBC-EDS)

35

Authors and
Year

Sample

Design

Time of
measurement

Follow-up time

Variables

Relevant
instruments

Main results

Pliner & Haddock,

1995

N=100, of which one

group had little
weight concerns and
one group had high
weight concerns
(group sizes remain
unknown)

Experimental

EAT administered several

weeks before experiment

No follow-up

Eating disorder
symptoms,
perfectionism,
positive affect,
sensation seeking,
anxiety, depression,
hostility

EAT, EDI, Multiple

Affect Adjective
Check List
(MAACL), and
several
questionnaires
specific to this
experiment

Price Foundation
Collaborative Group,
2001

N=348, of which 196

AN probands, 116
AN siblings, 36 BN
siblings

Multi-site study

Self-rating assessments
were completed before the
interview

No follow-up

Anxiety, harm
avoidance,
perfectionism,
general and
eating-specific
obsessivecompulsive
symptoms,
temperament and
character
components

SIAB (structured
interview), YaleBrown Obsessive
Compulsive Scale
(YB-OCS), YBCEDS, Stait Trait
Anxiety Inventory
(STAI), MPS, and
Temperament and
Character Inventory
(TCI)

Soenens, Nevelsteen
& Vandereycken,
2007

N=170, of which 67
with AN, 32 with
BN and 23 with
EDNOS, and a
control group of 48
women

Longitudinal

First measurement within

48 hours after admittance
to clinic, second
measurement during
second week of treatment,
last measurement in last
week of treatment

Two weeks after

admittance to clinic
and during the last
week of treatment

Adaptive and
maladaptive
perfectionism,
depression, eating
disorder symptoms

MPS, BDI, and EDI

Confirms that
anorexics conform to
high performance
expectations that
others have of them.
Anorexics continued
to strive for
unrealistically high
goals even when it
was clear these goals
were unreachable and
they were more
negatively affected
by feedback than
controls.
A combination
of trait anxiety, harm
avoidance,
perfectionism,
obsessive-compulsive
behavior, and
diminished selfdirectedness
underlies the cluster
of personality and
behavioral traits in
this sample
Scores for
maladaptive
perfectionism were
higher in the eating
disordered group than
the control group, and
only maladaptive
perfectionism
predicted symptom
severity.

36

Authors and
Year

Sample

Design

Time of
measurement

Follow-up time

Variables

Relevant
instruments

Main results

Terry-Short, Owens,
Slade & Dewey,
1994

N=281 women, of
which 225 healthy
controls, 21 eating
disordered, 20
successful athletes
and 15 depressed
women

Cross-sectional

Unknown

No follow-up

Positive
perfectionism,
negative
perfectionism,
personal
perfectionism,
socially prescribed
perfectionism

Watson, Raykos,
Street, Fursland &
Nathan, 2011

N=201 women with

DSM diagnosis of an
ED, from which 34
women with AN

Correlational

At admission to clinic

No follow-up

Self-oriented
perfectionism,
socially prescribed
perfectionism, shape
and weight
overevaluation,
conditional goalsetting, eating
disorder attitudes and
behaviors

A combination of
items from the MPS,
EDI, NPQ, Burns
Perfectionism Scale
(BPS), and the
Setting Conditions
for Anorexia
Nervosa Scale
(SCANS)
Diagnostic interview,
EDE-Q, EDI, and the
Conditional Goal
Setting in Eating
Disorders Scale
(CGS-EDS)

Perfectionism should
be divided into two
dimensions: positive
and negative
perfectionism.
Negative
perfectionism is
elevated in clinical
groups.
The relationship
between selforiented
perfectionism and
eating disorders is
mediated by shape
and weight
overevaluation and
conditional goalsetting.

37

Table 1b. Persistence of perfectionism and influence on response to treatment and prognosis.
Authors and
Year

Sample

Design

Time of
measurement

Follow-up time

Variables

Relevant
instruments

Main results

Bardone-Cone,
Sturm, Lawson,
Robinson & Smith,
2010

N=157 women, of
which 55 active ED
cases, 15 partially
recovered, 20 fully
recovered and 67
healthy controls

Cross-sectional

Questionnaires were
completed first, followed
by an interview later on

No follow-up

Perfectionism, bingeeating, vomiting, use

of laxatives,
disordered eating
thoughts and
behaviors

Bizeul, Sadowsky &

Rigaud, 2001

N=26 women, of
which 20 with AN (a
posteriori classified
into two groups:
'recovered' and 'poor
outcome') and 6 with
BN

Longitudinal

Post-diagnosis with AN

Every six months

after initial
assessment for at
least 5 years

Fully recovered
individuals and
controls had
comparable, low
levels of
perfectionism.
Shows that
perfectionism after
recovery is not an
evident outcome.
Results show that the
higher the score of
perfectionism and
'interpersonal
distrust', the worse
the prognosis. High
EDI scores were also
related to illness
severity.

Nilsson, Sundbom &

Hgglf, 2008

N=91, of which 90
girls with AN
restricting type and 1
boy (N=68 at last
follow-up)

Longitudinal

At admission to clinic,
first follow-up after 8
years and second followup after 16 years

8 and 16 years after

admission to clinic

Nutrition status,
menses, mental state
and psychosocial and
psychosexual
functioning, mental
functioning and
insight,
perfectionism, drive
for thinness, bulimia,
body dissatisfaction,
ineffectiveness,
distrust, maturity
fears
Socially prescribed
and self-oriented
perfectionism,
psychiatric
symptoms, mental
and physical health

Structured interview,
Eating Disorders
Longitudinal Interval
Follow-up
Evaluation interview
(LIFE EAT II),
EDE-Q, MPS, PSPS,
and Perfectionism
Cognitions Inventory
(PCI)
EDI, MorganRussell Outcome
Assessment
Schedule, and semistructured interview

Semi-structured
interviews, Symptom
Check List (SCL90), EDI, and Global
Assessment
Functioning (GAF)

Long-term recovered
patients had EDI
scores that were in
the normal range. At
2nd follow-up both
recovered and nonrecovered had high
scores on
perfectionism scale.
Patients with high
level of
perfectionism may
be at risk for longer
illness duration.

38

Authors and
Year

Sample

Design

Time of
measurement

Follow-up time

Variables

Relevant
instruments

Main results

Rigaud, Pennacchio,
Reveillard & Vergs,
2011

N=484 hospitalized
patients with AN, of
which 462 women
and 22 men

Longitudinal

At hospital admission, at
discharge and after that
every year for 13 years

Follow-up
assessments every
year for 13 years

Adapted versions of
the EDE-Q, EDI,
BDI, Hamilton
Anxiety Scale
(HAS), and the
Morgan-Russell
outcome scores

This study found a

low recovery rate
after two years,
which was linked to
factors such as low
BMI and high scores
on measures of
perfectionism. After
13,5 years, 60% of
the initial group was
recovered. The
others had poor or
severe outcomes.

Sutandar-Pinnock,
Woodside, Carter,
Olmsted & Kaplan,
2003

N=73 women with

AN, and a control
group of healthy
women

Longitudinal

EDI and EDE completed

within two weeks after
admission and follow up
measurements after 6 and
24 months

Follow-up at 6 and
24 months posttreatment

Symptoms and
feelings
(perfectionism,
anxiety, depression
etcetera) and disease
onset, change of
subtype, number of
hospitalizations,
body weight before
AN, highest body
weight before AN,
body weight loss,
lowest and highest
body weight during
AN, medical
complications, and
menstrual cycles.
Perfectionism and
eating disorder
symptoms

MPS, EDI, and EDE

Recovered AN
patients had similar
EDI perfectionism
scores as controls.
MPS perfectionism
scores were elevated
in AN patients when
compared with
controls, even when
AN patients were in
remission.

39

Figure 1. Flowchart of the literature selection.

Records identified through database searching

PsycINFO (n = 77)
PUBMED (n = 54)

Records after duplicates removed

(n = 88)
Records excluded based on title or
abstract, because of
1) Not written in Dutch or English
(n = 2)
2) Did not focus enough on the
relationship perfectionism-AN
(n = 34)

Full-text articles assessed

for eligibility
(n = 52)

Full-text articles excluded, because of

1) Focused more on other factors than
perfectionism (n = 18)
2) Focused on other populations (n = 14)
3) Focused too much on specific
treatment outcomes (n = 3)
4) Study design (reviews) or were books
(n = 4)
Additional records identified
through reference lists
(n = 6)

Studies included in review

(n = 19)

40